The present invention concerns an automated clinical records management system. Such system has utility, for example, in a hospital-based patient record-keeping system. Patient record-keeping systems are used for maintaining a wide variety of types of medical records concerning clinic or hospital patients
Hand-written patient record-keeping systems have evolved through many years of careful refinement and enhancement into systems which maintain a detailed manual record of medical information concerning each patient. To meet the needs of different hospital entities (such as doctors, nurses, pharmacy, accounting, laboratory, etc.) requiring access to such medical information, in a manual record-keeping system various medical information is logged into multiple types of records.
In a typical manual patient record-keeping system a patient chart, usually in the form of a notebook, is maintained at the nursing station for each patient. The notebook is divided into a plurality of individual tabbed sections, such as Physicians Orders, Kardex, Nursing Care Plan, Nursing Assessment, and Laboratory.
Each of the above sections is further subdivided into a number of forms. The forms are those which are appropriate to the individual patient and/or such patient's physician. For example, within the "Laboratory" section there may appear forms for Chemistry, Hematology, Blood Gas, and Microbiology.
In addition, a "Flowsheet" chart is usually kept at the patient's bedside. On the "Flowsheet" chart there typically appear individual areas for Medications Records, Vital Signs, Intake/Output, Laboratory Results, and other categories which are dependent upon the patient's affliction, such as Ventilator, which would be used if a patient were placed on a ventilator
One problem with a manual patient record-keeping system is the necessity to enter the patient name and associated personal identifying information such as i.d. number, bed location, etc. separately on each patient record form associated with a given patient This is typically done using an embossed card, similar to a credit card, containing the patient's personal information. However, this process consumes a certain amount of time, and errors may be result if two patients' cards are inadvertently switched.
Another problem with manual patient record-keeping systems is that, to meet the diverse requirements of the different hospital entities for whose benefit such patient records are kept, identical information must be recorded on different forms. Again this involves additional time-consuming work and frequently causes errors to be interjected into the patient records. In addition, desired patient information may be inaccessible to a legitimate user because it is stored on a form with which such user is unfamiliar or on a form which is being accessed by another user at that time.
A further problem with manual patient record-keeping systems is that it is difficult to extract patient care information for auditing and review purposes. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAH) stipulates many diverse requirements for providing documentation, and fulfilling such requirements is often difficult. Therefore, it would be beneficial to have a patient record-keeping system which provided a direct relationship between a physician's order and the documentation corresponding to that order (e.g. whether the order was completed, or the reasons that it wasn't completed).
It has been estimated that nurses' salaries account for 30%-40% of a hospital's operating budget, and that they spend 25%-40% of their time performing clerical and communications tasks. Because of changes in government regulation, insurance reimbursement policies, and competition, hospitals are increasingly under pressure to reduce their operational costs. As a result, hospital occupancy and patient length of stay have decreased, and more hospital patients are acutely ill. However, staffing levels have been reduced to cut costs. In addition, there often exist shortages of qualified nurses. Thus, hospitals are providing care for sicker patients with fewer people, and there is a significant need for making those people more productive through hospital automation.
To maximize the productivity of hospital staff and to maximize overall patient care by making optimum use of patient data, various automated clinical record-keeping systems have been proposed and even implemented.
While automated record-keeping systems are known which organize many types of information, including information relating to customers, clients, and even medical/dental patients, no automated clinical records management system is known which provides the unmistakable benefits of an automated system and yet which very closely parallels the organization and appearance of the conventional, familiar manual hospital records charting system.
In known automated hospital record-keeping systems the user interface is typically "machine-oriented". In a "machine-oriented" system the system typically waits for the user to generate commands. The user often must proceed several layers deep through a confusing hierarchy of on-screen menus to the desired screen level. Once there, it is all too easy for the user to forget which screen level he is working in, how he got there, how to return to a more fundamental screen level, and how to move to a different screen level or to a related screen level.
In a "user-friendly" system, the system electronically emulates the existing hospital forms on the screen display and provides easily accessible commands within the context of the form to let the user manipulate and review the information on such forms.
It would be very desirable to provide the users of an automated hospital record-keeping system with the capability of generating a time-oriented task list of all tasks which must be performed for each patient. In present record-keeping systems, time-oriented tasks are maintained on a variety of different forms or merely committed to memory, the result being that a nurse or other user must manually write up or attempt to remember a chronological checklist of tasks to be performed for each patient. Not only is the manual generation of such a list time-consuming, but all too frequently mistakes are made in recording such information or in recalling it from memory. Thus it has been found to be very desirable to generate a task list automatically from data which has been entered from physicians' and nursing orders.
In a manual clinical record-keeping system, when a nurse accomplishes a task, he/she must not only record its accomplishment on the associated form from which it originated, but he/she must also document on the manual checklist that the task was performed . Thus, it would be desirable if the tasks on such task list could be charted by a system user while viewing the task list and if the associated form(s) were automatically updated at the same time that each task on the task list is completed by the user. Additionally, it would be desirable to be able to chart directly from this chronological task list that a particular intervention or procedure has been performed without leaving the context of the chronological task list.
In addition, it would be desirable if a task could be charted by a system user directly onto one of the system forms and if, in so doing, the task list and any other associated form(s) were automatically updated.
It would also be desirable to automatically record the completion of each task and intervention as it is performed to complete the documentation requirement for proper patient care.